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  #1  
Old 09-20-2013
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Vascular Ankle Brachial Index Management

A 65 year old man with HTN presents to your office for evaluation of right leg pain that increases on walking about one block. The pain seems to disappear when he sits and takes rest for about 10 minutes. He is concerned because it is interfering with his exercise activity that his cardiologist has recommended him. His medications include hydrochlorthiazide and enalapril. The patient has a history of heavy smoking but he quit 2 years ago. Physical exam was normal except for diminished dorsalis pedis pulses bilaterally. An arterial doppler is performed and ankle brachial index obtained which is 0.70 . The next best step in the management of his leg pain?
A) Start Cilostozol
B) Start Pentoxyfilline
C) Supervised exercise therapy
D) Recommend unsupervised exercise for 30 minutes everyday.
E) Add clopidogrel.
F) Obtain Magnetic Resonance Angiography.
G) Arterial bypass surgery
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  #2  
Old 09-20-2013
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Want to improve exercise intolerance? then start with A.

Want to decrease mortality? then start clopidrogel (preferred over aspirin in PAD patients).

Because the question is asking for the next best step in management for the pain and that it would also increase his exercise tolerance at the same time I would go for option A
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Old 09-20-2013
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So I was thinking the same but it turned out the answer is C. As he is having difficulty mainly during exercise. Definitely next step is cilostazol.

And yeah you're right we prefer clopidrogel to aspirin in PAD patients. That was next question in sequence. Goodjob!
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Old 09-20-2013
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So I was thinking the same but it turned out the answer is C. As he is having difficulty mainly during exercise. Definitely next step is cilostazol.

And yeah you're right we prefer clopidrogel to aspirin in PAD patients. That was next question in sequence. Goodjob!
It may be partially correct because he says he has difficulty with exercise but doing a supervised exercise regime implies doubt.. Mainly using the House philosophy of "patients lie"

Again.. the question asks for the management of the "pain" which in this case only cilostazol could be chosen because it is the best drug for this purpose AND to increase 40-50% in his exercise tolerance.

If the question is from Archer then yeah.. for sure.. But I believe the correct answer on the boards is gonna be A.. Who knows tho
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Old 09-20-2013
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lol yes it's from archer. That's why I was confused coz A made more sense. yup don't know what they expect. Will be decided in that moment only
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lol yes it's from archer. That's why I was confused coz A maked more sense. yup don't know what they expect. Will be decided in that moment only

Yeah, archer likes to throw some curveballs like this. They are good !
I did archer a couple of months ago and thats why I somehow recognized this question's style.

When is your exam?
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Old 09-20-2013
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Idea!

Soon! in 2days. feeling the excitement plus nervousness
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Soon! in 2days. feeling the excitement plus nervousness


Good luck!you will do great!
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Smile

Thanks you!!
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Old 04-09-2016
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Originally Posted by XpaezX View Post
It may be partially correct because he says he has difficulty with exercise but doing a supervised exercise regime implies doubt.. Mainly using the House philosophy of "patients lie"

Again.. the question asks for the management of the "pain" which in this case only cilostazol could be chosen because it is the best drug for this purpose AND to increase 40-50% in his exercise tolerance.

If the question is from Archer then yeah.. for sure.. But I believe the correct answer on the boards is gonna be A.. Who knows tho
Thank you.
This is an awesome question. Evidence-based typical step 3 question.

Exercise rehabilitation is a class I, level of evidence A, recommendation for the treatment of claudication in patients with PAD.7,8 A landmark meta-analysis in 1995 demonstrated that supervised exercise improves claudication symptoms and increases pain-free walking distance on a treadmill by >100%.18 In 2008, a rigorous systematic review by the Cochrane group19 involving 1200 participants from 22 randomized trials with stable claudication demonstrated a significant benefit in improving treadmill walking time and walking distance with a supervised exercise program. Although no benefit was seen in reducing major adverse cardiovascular events or on improving the ABI, subjects randomly assigned to exercise had improvement in claudication symptoms out to 2 years

http://circ.ahajournals.org/content/126/4/491.full
http://www.escardio.org/Guidelines-&...artery-disease


From Up-To-date : recommends an exercise therapy program as part of the initial treatment regimen for patients with claudication based upon randomized trials demonstrating significant improvements in walking parameters for those who participate. Specific pharmacologic therapy of claudication is aimed at improving symptoms and increasing walking distance in patients with lifestyle-limiting claudication, particularly if risk modification and exercise therapy have not been effective and revascularization cannot be offered or is declined by the patient. For patients with lifestyle-limiting claudication, we suggest a therapeutic trial (three to six months) of either cilostazol or naftidrofuryl depending upon availability.

So answer seems to be C
First exercise therapy. ( Class IA evidence)
If patient does not respond to exercise therapy or those patients who can not participate oin exercise therapy, next step is Cilostozol ( Class IB evidence)
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